ptsd Notes From My C&p Appointment

[icecube1986]

Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: 309.81 Mental Disorder Diagnosis #2: MDD Single Episode Page 26 of 160 Moderate ICD Code: 296.22 Mental Disorder Diagnosis #3: Obstructive Sleep Apnea Hypopnea ICD Code: 327.23 Mental Disorder Diagnosis #4: Alcohol Use D/O, Severity Unspecified ICD Code: 305.00 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to Medical 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes[ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes[ ] No[ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: There is some symptom overlap. Alcohol d/O symptoms are listed in Substance Abuse box, and also contributes to insomnia, poor impulse control, and concentration/memory impairment. OSA can cause or contribute to depressed mood, insomnia, daytime fatigue/sleepiness, and memory/concentration issues. MDD symptoms are listed in Other Symptoms box by DSM-5 criterion number. The remaining symptoms are wholly or partially the product of PTSD. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Page 27 of 160 Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: PTSD 40%, MDD 40%, Alcohol 10%, OSA 10%. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[ ] No[X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No Page 28 of 160 Was the Veteran's VA claims file (hard copy paper C- file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: Buddy Statements in VBMS 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: (Relocates so he can sit facing the door; ) Living with wife, son. We have ups and downs, she moved out a couple times and returned. She said she wasafraid for her life; we had a fight one time, second time I had been drinking and had my gun. Wife is trying to work with me currently. b. Relevant Occupational and Educational history: Has had job twice, had 'issues' with anger and with memory. One was with Domino's and would get mad about it. He is in school but fails a lot of tests due to poor concentration. Full- Time Barber School, some internet, mostly live classes.Page 29 of 160 c. Relevant Mental Health history, to include prescribed medications and family mental health: Currently Paroxetine, been on it a month after hiatus. Also getting counseling Hinesville. d. Relevant Legal and Behavioral history: police came to house one time and made me leave the house, stayed with relative for a while. Then wife left and I returned. e. Relevant Substance abuse history: I pretty much drink every day, beer 2 or 3, or 2 or 3 mixed drinks, maybe more. A pint of whiskey per day. Occasionally violates pre-set limits. Annoyed when wife brings it up. No diversion of funds. Some morning drinking. No withdrawal. No exclusion of activities. Not told it affects my health. f. Other, if any: Denies MST, denies TBI 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition ( DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Page 30 of 160 [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, Page 31 of 160 activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep Page 32 of 160 Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Neglect of personal appearance and hygiene 5. Behavioral Observations: --------------------------- Tall, tattooed male dressed all in black, appears adequately groomed and clean. Mood is Page 33 of 160 dysphoric throughout with blunted affect and no humor. There is mild psychomotor retardation. He ambulates without assistive device. Marginally adequate rapport is attained. Responses are sparse but germane. He relocates his chair so he can see both the room door and the restroom door. There are no signs of a thought D/O or cognitive D/O. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes[ ] No If yes, describe: MDD symptoms endorsed by patient per DSM-5 criterion number: A1, A2, A3, A4, A5 retardation, A6 (has OSA), A7, A8, A9. Meets B, C, D and E. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Day? Get up, feel hung over even if not drinking, no motivation, get ready for school, sometimes I skip, do my school work, sometimes eat with others, go home. No cooking. Has road rage, Honks horn, cusses. I do to Wal-Mart if I have to mostly with wife, but avoid it. No restaurants. Wife helps son with homework, has no events at school. I do help get him ready in morning. Lately no hobbies. Uses internet, facebook, e-benefits account, look up subjects. No exercise. Reports SI w/o plans, has crisis line number, agrees to pick up gun lock from VA Police today and to have wife hide gun. Denies MST. DSM-5 used throughout.

[Berta]

If you do not fall into the 2010 PTSD criteria here, do you have proof of your stressor?

[Matthew Hill]

icecube1986

Your rating should be 70%. The C&P form has that standard occupational language and whatever box is checked makes it easy for the VA rater to rate you on. The problem with this exam is that the specific findings in your case-- impulse control, suicidial ideation, and inability to maintain relationships-- are all indicative of a 70% rating. Additionally, if you are not working or making less than $10,000/yr you need to consider a claim for unemployability.

Odds are that that rater takes the easy road and rates you at 30% based on that one question. But you cannot stop there. With the symptoms that you have VA must recognize how much it affects your day to day life.

[icecube1986]

I called my vso today ...didn't know i had one but he couldnt tell me anything

[icecube1986]

Berta i was diagnosed with ptsd in 2011 and referred to mental health while in the army....i have been seeing the mental health doc for a little over a year at the va clinic

Edited June 3, 2015 by icecube1986

[icecube1986]

Mathew thats what i said when i read it but idk i went in and told him exactly how i felt no lies no fabrication ...i will appeal it most definitely

[icecube1986]

Moved from Pfd ...to pfn ...still no news ...hopefully in a week or so